Help for Pregnant Women with Anxiety or Depression

Last week I met with a group of family physicians and obstetricians during grand rounds at a local community hospital. I was invited to give a presentation on perinatal mental health, especially during pregnancy.

Why?

Because while postpartum depression is often the focus of the medical community and the public alike, the fact is that up to 80% of women who struggle with postpartum depression had symptoms that could have been detected first in pregnancy. Early detection and treatment could save months of hardship to women and their families.

After the presentation, we had a long conversation about several frustrations these clinicians experienced, including:

what screening tools used to detect anxiety or depression in pregnant women;

how to help women who need and want help;

frustration with the lack of services in the community (of almost 1-million people!) and the intolerable wait time to get women into one of the only existing services in the city.

This is not the first time I’ve heard these sentiments. This is the situation in North America for many primary care providers.

Let me provide some guidance surrounding these issues.

Detecting Anxiety and Depression in Pregnancy

Question: What screening tools should be used to detect anxiety or depression in pregnant women?

A major challenge in primary care is, as we all know, lack of time. Our research shows that the majority of women don’t talk to their doctors about emotional health issues because there just isn’t enough time, and they’re not sure whether what their experiencing is just a part of “normal” pregnancy. Women have told us they want to be “good patients,” and so they don’t bring up concerns about anxiety, stress or depression they have.

However, 97% of women also told us in a provincial survey that if their provider asked them first about emotional health, they would be pleased to respond and could be honest with them.

The NICE guidelines that were published in December 2014 presented (in my view) the best solution. They recommended two validated, but very brief, questionnaires that could be asked in any primary care setting in under 5 minutes. Remember: these are not DIAGNOSTIC tools. They are screening questions that can efficiently identify women that are struggling and require a more in-depth follow-up.

For depression, they recommended the 2-question Patient Health Questionnaire (PHQ-2):

Over the past 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things

Feeling down, depressed or hopeless

For each question, answer: 0=Not at all; 1=several days; 2=more than half the days; 3=nearly every day

Notes: The score ranges from 0-6. If a woman scores 3 or more based on adding her score to question 1 and question 2, she should receive a follow-up appointment with a clinician who can conduct a more thorough assessment of her needs or be referred to a cognitive behaviour therapy program.

Over the last 2 weeks, how often have you been bothered by the following problems:

Feeling nervous, anxious, or on edge

Not being able to stop or control worrying

For each question, answer: 0=Not at all; 1=several days; 2=more than half the days; 3=nearly every day

Notes: The score ranges from 0-6. If a woman scores 3 or more based on adding her score to question 1 and question 2, she should receive a follow-up appointment with a clinician who can conduct a more thorough assessment of her needs or be referred to a cognitive behaviour therapy program.

These tools are not perfect – none is! But, they are quite accurate and are brief enough to be used as a part of routine prenatal care. The best part is that our research shows that 99% of pregnant women who had not been screened for prenatal anxiety or depression wanted to be. In fact, in follow-up interviews, women told us they wanted to be routinely screened for emotional health – just like they had their blood pressure checked.

Question: What type of help can I offer pregnant women so that they can get timely assistance?

Research shows that 95% of pregnant women with emotional health concerns experience mild- or moderate-degree symptoms.

That means that the vast majority of women can be effectively helped through online venues, which are cheaper, more available, and readily accessed than face-to-face sessions (which may not be an option in smaller communities).

The NICE guidelines suggest that there is enough evidence to recommend cognitive behaviour therapy (CBT) to pregnant women with mild- or moderate- symptoms.

My Compass (https://www.mycompass.org.au/). A free, personalized self-help online program that targets depression, anxiety or stress. Move through at your own pace. Plenty of great resources.

Another excellent option is an online CBT program that is being tested across Canada and is specifically for pregnant women.

The HOPE-STEP online CBT is our nationally-funded trial to determine if online CBT can reduce prenatal anxiety and depression.

Over 90% of women in the study to date told us that they found the online CBT very helpful, and said they would recommend it to a pregnant friend who was struggling.

The study is open for all pregnant women <36 weeks of pregnancy who are:

currently struggling with depression, anxiety, or stress;

at risk for an emotional problem during pregnancy (e.g., have a history of anxiety or depression);

not struggling and have no risk (researchers are assessing whether an online CBT in pregnancy can prevent postpartum depression and anxiety).

We continue to monitor and provide support for women from pregnancy through to 1-year after delivery.

As part of this trial, women are compensated 10$ for each of the 6-online CBT modules that they complete. They are also given 10$ for each of the 5 surveys that they finish.

To sign up, women or their provider can email marie.lanesmith@ucalgary.ca. As of Wednesday, May 25/16 they can also sign up through an online link at www.hope-research.com

The last 5% of women who have more severe symptoms, and often co-existing challenges such as lack of support, interpersonal violence, or substance use, are best served by a combination of multidisciplinary services that may require coordination between a psychiatrist, family physician, psychologist, and/or social worker.

Feel Free to Contact Me

I hope this helps. Feel free to direct your questions and comments below in the comment section, or contact me directly at: dawn.kingston@ucalgary.ca